Lipids 101 - PowerPoint PPT Presentation


PPT – Lipids 101 PowerPoint presentation | free to download - id: 84e278-YjY2Z


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Lipids 101


Lipids 101 Cardiology Board Review Med-Peds Style! Inherited Dyslipidemias Metabolic Syndrome Abdominal obesity (40 in men; 35 in women Atherogenic ... – PowerPoint PPT presentation

Number of Views:88
Avg rating:3.0/5.0
Slides: 28
Provided by: Pradn1


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Lipids 101

Lipids 101
  • Cardiology Board Review
  • Med-Peds Style!

(No Transcript)
Americans requiring treatment for Hyperlipidemia
Therapeutic Lifestyle Changes (TLC) Drug
CHD and CHDRisk Equivalents 24.1 20.710-year
risk gt20 2 Risk Factors 10.9 8.310-year
risk 1020 2 Risk Factors 14.6 2.810-year
risk lt10 01 Risk Factor 15.6 4.7 Total
65.3M 36.5M
Inherited Dyslipidemias
Metabolic Syndrome
  • Abdominal obesity (gt40 in men gt35 in women
  • Atherogenic dyslipidemia
  • Elevated triglycerides (gt150mg/dl)
  • High LDL
  • Low HDL (lt40 in men lt50 in women)
  • Raised blood pressure (gt130/85)
  • Insulin resistance (? glucose intolerance)
  • Fasting glucose gt110mg/dl
  • Prothrombotic state
  • Proinflammatory state

3 Orange Criteria Diagnosis!
Risk Assessment
  • Measure fasting LDL in all patients beginning at
    age 20yo.
  • For patients with multiple (2) risk factors
  • Recheck LDL every 5 years
  • For patients with 01 risk factor
  • 5 year risk assessment not required
  • Most patients have 10-year risk lt10

Major Risk Factors (Exclusive of LDL) That Modify
LDL Goals
  • Cigarette smoking
  • Hypertension (BP ?140/90 mmHg or on
    antihypertensive medication)
  • Low HDL cholesterol (lt40 mg/dL)
  • Family history of premature CHD
  • CHD in male first degree relative lt55 years
  • CHD in female first degree relative lt65 years
  • Age (men ?45 years women ?55 years)

CHD Risk Equivalents
  • Other clinical forms of atherosclerotic disease
    (peripheral arterial disease, abdominal aortic
    aneurysm, and symptomatic carotid artery disease)
  • Diabetes (10-year risk for CHD 20)
  • Multiple risk factors that confer a 10-year risk
    for CHD gt20

Lifestyle Risk Factors
  • Obesity (BMI ? 30)
  • Physical inactivity
  • Atherogenic diet

Causes of Secondary Dyslipidemia
  • Diabetes
  • Hypothyroidism
  • Obstructive liver disease
  • Chronic renal failure
  • Drugs that raise LDL cholesterol and lower HDL
    cholesterol (progestins, anabolic steroids, and

Primary Prevention With LDL-Lowering Therapy
  • Public Health Approach
  • Reduced intakes of saturated fat and cholesterol
  • Increased physical activity
  • Weight control

Secondary Prevention With LDL-Lowering Therapy
  • Benefits reduction in total mortality, coronary
    mortality, major coronary events, coronary
    procedures, and stroke
  • LDL cholesterol goal lt100 mg/dL
  • Includes CHD risk equivalents
  • Consider initiation of therapy during
    hospitalization(if LDL ?100 mg/dL)

LDL Goals and Cutpoints for Therapeutic Lifestyle
Changes (TLC) and Drug Therapy
Risk Category LDL Goal(mg/dL) LDL to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL to ConsiderDrug Therapy (mg/dL)
CHD or CHD Risk Equivalents(10-year risk ?20) lt100 ?100 ?130 (100129 drug optional)
2 Risk Factors (10-year risk ?20) lt130 ?130 10-year risk 1020 ?130 10-year risk lt10 ?160
01 Risk Factor lt160 ?160 ?190 (160189 LDL-lowering drug optional)
July 14, 2004 NCEP updated stratified
cholesterol guidelines
  • Very high risk individuals patients with CAD
    AND DM, uncontrolled HTN, or metabolic risk
    factors including obesity, high triglycerides,
    and low HDL. Smokers with CAD. Goal of
    therapy--LDL lt 70 mg/dl
  • High-risk individuals CAD or DM or multiple
    risks factors -- Goal of therapy--LDL lt 100 mg/dl

July 14, 2004 NCEP updated stratified
cholesterol guidelines
  • Moderately high risk Multiple risk factors for
    CAD with a 10 to 20 chance of having an MI or
    cardiac death within a decade. If the LDL level
    is between 100-129 mg/dl then a statin drug may
    be started. Goal of therapy--LDL lt 100 mg/dl
  • Lower or moderate risk Dietary changes and
    exercise unless LDL levels are very high

LDL-Lowering TherapyHow low do we go?
  • Baseline LDL lt100 mg/dL
  • Further LDL lowering not required except in CHD
    and CHD risk equivalent then use LDL lt70
  • Therapeutic Lifestyle Changes (TLC)
  • Consider treatment of other lipid risk factors
  • Elevated triglycerides
  • Low HDL cholesterol

HMG CoA Reductase Inhibitors (Statins)
  • Reduce LDL-C 1855 TG 730
  • Raise HDL-C 515
  • Major side effects
  • Myopathy
  • Increased liver enzymes
  • Contraindications
  • Absolute liver disease
  • Relative use with certain drugs

Bile Acid SequestrantsCholestyramine,
Colestipol, Colesevelam
  • Major Actions
  • Reduce LDL-C 1530
  • Raise HDL-C 35
  • May increase TG
  • Side effects
  • GI distress/constipation
  • Decreased absorption of other drugs
  • Contraindications
  • Dysbetalipoproteinemia
  • Raised TG (especially gt400 mg/dL)

Nicotinic Acid
  • Major actions
  • Lowers LDL-C 525
  • Lowers TG 2050
  • Raises HDL-C 1535
  • Side effects flushing, hyperglycemia,
    hyperuricemia, upper GI distress, hepatotoxicity
  • Contraindications liver disease, severe gout,
    peptic ulcer

Fibric AcidsGemfibrozil, Fenofibrate, Clofibrate
  • Major actions
  • Lower LDL-C 520 (with normal TG)
  • May raise LDL-C (with high TG)
  • Lower TG 2050
  • Raise HDL-C 1020
  • Side effects dyspepsia, gallstones, myopathy
  • Contraindications Severe renal or hepatic disease

If LDL goal not achieved, intensify drug therapy
or refer to a lipid specialist If LDL goal
achieved, treat other lipid risk factors
If LDL goal not achieved, Consider higher dose of
statin or add a bile acid sequestrant or
nicotinic acid
Start statin or bile acid sequestrant or
nicotinic acid AFTER 3 MONTHS OF TLC
6 wks
6 wks
Q 4-6 mo
Classification of Serum Triglycerides
  • Normal lt150 mg/dL
  • Borderline high 150199 mg/dL
  • High 200499 mg/dL
  • Very high ?500 mg/dL

Management of Very High Triglycerides (?500 mg/dL)
  • Goal of therapy prevent acute pancreatitis
  • Very low fat diets (?15 of caloric intake)
  • Triglyceride-lowering drug usually required
    (fibrate or nicotinic acid)
  • Reduce triglycerides before LDL lowering

Causes of Low HDL Cholesterol (lt40 mg/dL)
  • Elevated triglycerides
  • Overweight and obesity
  • Physical inactivity
  • Type 2 diabetes
  • Cigarette smoking
  • Very high carbohydrate diet (gt60)
  • beta-blockers, anabolic steroids, progestational

Management of Low HDL Cholesterol
  • LDL cholesterol is primary target of therapy
  • Weight reduction and increased physical activity
    (if the metabolic syndrome is present)
  • Non-HDL cholesterol is secondary target of
    therapy (if triglycerides ?200 mg/dL)
  • Consider nicotinic acid or fibrates (for
    patients with CHD or CHD risk equivalents)

Previous In-service Topics
  • Hyperlipidemia due to secondary causes
  • Statin associated myositis
  • Target LDL in DM and HTN
  • Which statin is least likely to be metabolized by
    P450 and least likely to interact with
  • Causes of hypertriglyceridemia

Food for Thought
  • "The average American may be fine with an LDL of
    120, but when we're born we have an LDL of 25 or
    30. If we put statins in the drinking water,
    would it help public health? Yes, but public
    health endeavors would help more.
  • Our obesity epidemic needs to be conquered not
    with medicine but with effective change for the
    whole population. If you're looking at
    cost-effectiveness, its time to teach young
    people to eat right and exercise. We can do that
    -- or we can start throwing 10 medicines at them
    when they are 40 or 50 years old."
  • -Lawerence S. Sperling, MD Director of Emory
    Heart Center Risk Reduction Program